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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: {209}468-3420 Fax: (209)464-0138 Web:www.sjgov. <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> !P <br /> APPLICANT: Yan` rraRY BUSINESS/AGENCY: ::VJh1C wE (amf <br /> ADDRESS: M City/State/Zip <br /> PHONE(1): , GS 'S1 r6. 0_ O PHONE(2): 120. 1?:' .�£–` FACSIMILE: <br /> TENTATIVE"APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-'Tentative only-must be confirmed) <br /> CHECK BOX TO EXPEDITE RRE-QUUElST-$105 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE _ NZ Ikd r;,, <br /> Electronic Information: ❑List❑Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name _City ❑ Unit 1 <br /> 2. Unit 2 <br /> 3. <br /> 4 Unit 3 <br /> 5. <br /> — ----............-.--- ----- nit 4 <br /> 6. <br /> 7. _ ❑ Uni <br /> 8. <br /> 9. <br /> ❑ Unit 6 <br /> 10. <br /> Specific Date Range of Information Requested:From -2000 to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> Q UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITY1VEHICLE <br /> BOTHER CLEANUP SITE(NON-LOP) O FOOD FACILITY ❑WASTE TIRE <br /> E7 UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL ❑DAIRY <br /> Q HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH If WASTEWATER TREATMENT PLANT <br /> O TIERED PERMITTED FACILITY O MOTEL/HOTEL 13' UMPER TRUCK/YARD/CHEM TOILETS <br /> TATTOO/BODY PIERCING O POOL/SPA �j LAND USE APPLICATION SITES <br /> 13'MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW-MON DAY-FRIDAY 8:00 AM-5:00PM -EXCLUDING HOLIDAYS. <br /> 1. List up to ten addresses in the space above. Select the type(s)of files from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(209)_464.0138 or mail to the address indicated above. Address <br /> ranges will not be accepted—for additional assistance with file addresses,contact the EHD. Applications received after <br /> 3:00 pm will be processed the next business day. <br /> 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten(10) <br /> days after receipt of application. The files will be held for a maximum of five business days for review. Appointments <br /> should be scheduled accordingly. <br /> 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be <br /> submitted when the file is available. <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a$105 deposit prior to review. <br /> EHD USE ONLY <br /> EHD 48.08 8/04108 PUBLIC RECORDS RELEASE APP FORM <br />